Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
For patients with kidney stone disease and chronic kidney disease, is there an eGFR threshold at which you no longer recommend pursing 24 hour urine stone risk studies?
While I agree with Dr. Erickson's comments in general, though, I have encountered patients that newly presented for stone disease at late stages of CKD and even on dialysis. The critical consideration is whether there is evidence of ongoing stone formation/growth. We must be aware that a stone passa...
How do you approach hematuria in a patient with diabetic nephropathy?
This is a difficult question to answer. If young, no risk factors for GU malignancy and only microscopic hematuria would generally not pursue but make patient aware of small risk and make sure PCP also knows. Helpful to know if red cells are dysmorphic and if there is also proteinuria. Gross hematur...
Would you recommend dual antiplatelet therapy or anticoagulation for a patient previously on aspirin who has a breakthrough stroke with history of CADASIL?
CADASIL is a genetic condition with a presumed mechanism of vascular injury to be disruption of the blood-brain barrier and non-atherosclerotic angiopathy. Thus, it makes sense that no anti-thrombotic has been show to reduce stroke risk. It's expert consensus to do daily aspirin, but this is more to...
What is the optimal antithrombotic management, if at all, in patients with incidentally identified findings of multiple silent embolic appearing cerebral infarcts?
It is important to confirm the pattern is embolic. If unsure, input from a specialized physician (such as vascular neurology or neuro-radiology, if available) can aid in confirming the diagnosis. Various white matter findings may mimic an embolic pattern, and distinguishing between unilateral...
How do you decide when to use andexanet (ANDEXXA) for intracranial hemorrhage associated with factor Xa inhibitors?
The ANNEXA-I trial presents a mixed perspective. The data demonstrated that Andexanet is superior to standard care in reducing hematoma expansion for intracerebral hemorrhage associated with factor Xa inhibitors. This conclusion is based on an imaging-based primary endpoint, supported by previous st...
What is the role of non-prednisone oral glucocorticoids in the management of systemic rheumatologic disease?
I saw this question and thought it was really interesting. I did some preliminary research on the topic and was amazed at how little is actually written in the scientific literature. Perhaps someone reading this can perform a search and offer some thoughts. I decided to write to start a dialogue on ...
For which patients with calciphylaxis would you recommend a parathyroidectomy?
In those with refractory hyperparathyroidism (typically PTH above 800-1000 pg/mL) despite medical therapies like cinacalcet.
When should one consider obtaining a cardiac MRI in ischemic stroke patients?
This is a terrific question. Cardiac MRI is increasingly utilized in the diagnostic evaluation of ischemic stroke and can uncover clinically covert cardiovascular disease. The clinical utility in ischemic stroke is most in patients with concern for LV thrombus (low EF or recent anterior ST elevation...
How do you complete brain death testing in patients who cannot tolerate apnea testing and are unable to transport for ancillary testing?
The short answer is that you cannot. Brain death diagnosis requires the presence of 3 conditions: persistent coma, absence of brainstem reflexes, and lack of ability to breathe independently. If portions of the clinical exam or apnea test cannot be performed, ancillary testing is necessary to make t...
Should you consider thromboprophylaxis, even for low-dose lenalidomide maintenance, post-autologous transplantation?
In the event there are no adverse contraindications for the use of thromboprophylaxis, yes, I recommend the use of a minimum of 81 mg of aspirin daily with a low dose of lenalidomide. In this meta-analysis (Chakraborty et al., PMID 31913498), the risk of venous thromboembolism was low with a low dos...